Thursday, August 2, 2012

Curbing the costs of high-tech health - The Washington Post

Advances in medical technology are a double-edged sword. On the one hand, they have brought huge health gains to millions of Americans. Hip and knee replacements, heart operations, brain surgery, drugs — treating everything from high cholesterol to depression — have become routine when they were once considered exotic or unimaginable. The drawback is that these same breakthroughs have driven health spending upward, because they're prone to misuse and overuse.

Can we curb waste without undermining new technologies? Well, maybe.

We now have a study suggesting, optimistically, that proper incentives can concentrate new technologies on the patients who might most benefit. The study involves advanced diagnostic imaging, including CT scans (for computed tomography) and MRIs (for magnetic resonance imaging). From 2000 to 2005, CT and MRI use among Medicare recipients grew 14 percent annually. Now, growth of both Medicare and non-Medicare spending has slowed to estimated annual rates of 1 percent to 3 percent, the study says.

Imaging represents one of the great medical achievements since World War II. Until the 1970s, when CT scans appeared, traditional X-rays were the only way doctors could peer inside the body. X-rays' most conspicuous limitation is that they can't penetrate deeply into the brain. "The first CT scans were so exciting because you could see the brain much better," says Yale historian Bettyann Kevles, author of "Naked to the Bone: Medical Imaging in the Twentieth Century."

What CT scans can't show, MRIs usually can. For example, CT scans are less able to image soft tissue (ligaments, tendons, nerves and blood vessels). "The two of them together give a good picture of the entire body," says Kevles.

Better imaging is a natural ally in diagnosing many diseases and ailments: heart disease, cancer, spinal injuries, strokes and bone and muscle pain. Not surprisingly, costs ballooned. In 2009, Medicare paid $11.7 billion for medical imaging, according to Kaiser Health News.

Controlling spending on medical advances isn't easy, because it's favored by a three-legged alliance. First, patients want the newest and best care. Second, hospitals' and doctors' incomes often depend on using diagnostics and procedures in which they have invested. Finally, device and drug manufacturers want big markets for their products. There are huge pressures to apply medical advances to borderline cases where they might not be helpful.

The slowing growth of medical imaging might reflect a natural saturation: Scans are being used in most plausible clinical situations.

But the new study, posted on the Web site of the journal Health Affairs, disputes this. It argues that rapid growth was driven partly by powerful non-medical forces: Demanding patients insisted on scans; doctors feared malpractice suits if they refused; and doctors and hospitals wanted to maximize revenues. What explains slower growth is that these incentives weakened, contend economists Frank Levy of the Massachusetts Institute of Technology and David Lee of General Electric. (Note: GE is a major supplier of imaging equipment.)

One change was the adoption of prior authorization by many private insurers. Doctors usually had to get permission for advanced imaging and, if patients' conditions didn't comply with guidelines, explain why. This may have discouraged referrals, because doctors don't like being overruled. Patients also became less demanding, because deductibles and co-payments rose. From 2006 to 2010, the share of workers with deductibles exceeding $1,000 grew from 10 percent to 27 percent. "Increased out-of-pocket expenses have made patients and physicians more cost conscious," write Levy and Lee.

Finally, some reimbursement rates fell. In 2005, Congress mandated that Medicare couldn't pay free-standing imaging centers — often owned by doctors — more than it paid hospitals for outpatient imaging. This "reduced profits for imaging centers and resulted in extensive consolidation in the industry," the study said. Under complex reimbursement rules, doctors had incentives to establish imaging centers or install scanning devices in their offices, says Levy. And these imaging centers seemed "particularly active in stimulating demand."

Have patients suffered from less imaging? Comprehensive studies haven't been done, but Levy and Lee provide evidence of limited effects. Data from one insurance group suggested that about half the MRI slowdown involved lower back, elbow and knee pain. These cases often respond to "conservative treatment, including exercise," they write. "Instead of ordering an MRI at the outset, a physician can prescribe conservative treatment and order a scan if the problem persists."

The larger lesson involves better ways to police new technologies. The question is "how to stop physicians from just going with the flow and thereby breaking the bank," says Levy. Some combination of prior notification, higher patient co-payments and restrained reimbursements might do the trick.

Wednesday, August 1, 2012

NIH video reveals the science behind yoga, August 1, 2012 News Release - National Institutes of Health (NIH)

A video featuring research on how yoga works, the safety of yoga and whether yoga can help treat certain health problems is being released by the National Center for Complementary and Alternative Medicine (NCCAM), part of the National Institutes of Health (NIH). For example, there is a growing body of evidence that yoga may be beneficial for low-back pain. However, yoga has not been found helpful for treating asthma, and studies investigating yoga for arthritis have had mixed results.

The video also spotlights a set of consumer tips to help viewers make decisions if they are interested in practicing yoga. For example:

  • Yoga is generally considered to be safe in healthy people when practiced appropriately under the guidance of a well-trained instructor. However, people with high blood pressure, glaucoma, or sciatica, and women who are pregnant should modify or avoid some yoga poses.
  • Everyone's body is different, and yoga postures should be modified based on individual abilities. Inform your instructor about any medical issues you have, and ask about the physical demands of yoga.
  • If you're thinking about practicing yoga, be sure to talk to your health care providers. Give them a full picture of what you do to manage your health.

A 2007 Centers for Disease Control and Prevention survey reported that 13 million American adults (6 percent) used yoga in the previous year, and the number is on the rise as mind and body therapies are becoming increasingly integrated into the health care system. Due to a growing body of evidence-based research, the American College of Physicians and the American Pain Society now include a number of mind and body approaches, including yoga, in their 2007 clinical practice guidelines for managing chronic low-back pain, a common and difficult-to-treat problem.

"This video provides important information on the safety and usefulness of yoga and also insights into how scientists study this commonly used health practice," said Josephine P. Briggs, M.D., director of NCCAM. "What we're seeing from our researchers — through the application of rigorous scientific methods — is evidence suggesting that yoga may help people manage certain symptoms while it may not help with others. We're also learning more about the safety of yoga, particularly when it is used in populations who are at increased risk for injury."

The video, available at, highlights the work of two respected researchers in the field of yoga. George Salem, Ph.D., at the University of Southern California, uses innovative technology to examine how older adults use their muscles and joints in certain yoga postures. Karen Sherman, Ph.D., M.P.H, at Group Health Research Institute in Seattle, focuses on how yoga may be a beneficial complementary health practice for people with chronic low-back pain.

This is the second installment in NCCAM's The Science of Mind and Body Therapies video series. The first video, Tai Chi and Qi Gong for Health and Well-Being, was released in September 2010.

More Treatment, More Mistakes - Sanjay Gupta -

DOCTORS make mistakes. They may be mistakes of technique, judgment, ignorance or even, sometimes, recklessness. Regardless of the cause, each time a mistake happens, a patient may suffer. We fail to uphold our profession's basic oath: "First, do no harm."

According to a 1999 report by the Institute of Medicine, as many as 98,000 Americans were dying every year because of medical mistakes. Today, exact figures are hard to come by because states don't abide by the same reporting guidelines, and few cases gain as much attention as that of Rory Staunton, the 12-year-old boy who died of septic shock this spring after being sent home from a New York hospital. But a reasonable estimate is that medical mistakes now kill around 200,000 Americans every year. That would make them one of the leading causes of death in the United States. Why have these mistakes been so hard to prevent?

Here's one theory. It is a given that American doctors perform a staggering number of tests and procedures, far more than in other industrialized nations, and far more than we used to. Since 1996, the percentage of doctor visits leading to at least five drugs' being prescribed has nearly tripled, and the number of M.R.I. scans quadrupled.

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not. In a recent anonymous survey, orthopedic surgeons said 24 percent of the tests they ordered were medically unnecessary. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.

Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error. CT and M.R.I. scans can lead to false positives and unnecessary operations, which carry the risk of complications like infections and bleeding. The more medications patients are prescribed, the more likely they are to accidentally overdose or suffer an allergic reaction. Even routine operations like gallbladder removals requireanesthesia, which can increase the risk of heart attack and stroke.

So what do we do to be safer? Many smart people have tackled this question. Peter Pronovost at Johns Hopkins developed a checklist shown to bring hospital-acquired infections down to close to zero. There are rules against disturbing nurses while they dispense medications and software that warns doctors when patients' prescriptions will interact badly. There are policies designed to empower nurses to confront doctors if they see something wrong, even if a senior doctor is at fault.

What may be even more important is remembering the limits of our power. More — more procedures, more testing, more treatment — is not always better. In 1979, Stephen Bergman, under the pen name Dr. Samuel Shem, published rules for hospitals in his caustically humorous novel, "The House of God." Rule No. 13 reads: "The delivery of medical care is to do as much nothing as possible." First, do no harm.

One place where I have seen these issues addressed is in Morbidity and Mortality, or M and M — a weekly gathering of doctors, off limits to the public, which serves in most hospitals as a forum for the discussion of mistakes, complications, deaths and unusual cases. It is a sort of quality-assurance conference where doctors hold one another accountable and learn from one another's mistakes. They are some of the most candid and indelible meetings I have ever attended.

I will never forget when one of our most talented surgeons operated on the wrong side of someone's brain. The patient was bleeding internally; everyone was rushing, and someone had hung up the CT scans backward. Thankfully, the patient survived. The distraught doctor spent hours throwing up following the operation.

After he told the story in our M and M meeting, the hospital implemented a "time out" protocol in the operating room for everyone to stop and agree on what operation would be performed, on what side of the body, and whether the correct patient was indeed lying on the operating table, to make sure that kind of mistake would never happen again.

At my first M and M as a medical student, I heard the story of a patient who had received antibiotics for an upper respiratory tract infection. Two weeks later she developed joint pain and blisters on her chest and arms, a condition known as Stevens-Johnson syndrome, which can be caused by an allergic reaction to antibiotics. She ended up with sepsis, a bodywide infection, and spent two weeks in intensive care. She, too, survived, but most stunning was the doctor's admission that her original ailment had been a mild viral illness — she hadn't even needed the antibiotics that led to such a terrible reaction. Years later, that case still makes me think harder about every test I order and every medication I prescribe.

Hospitals are supposed to take care of the sickest members of our society and uphold the highest standards of patient care. But hospitals are also charged with teaching doctors, and every doctor has a first mistake. The only thing we can do is learn each time one happens, and reduce future errors in the process. Having a consistent gathering to talk about the mistakes goes a long way toward that goal, and just about any institution, public or private, could benefit from a tradition like M and M. It is not enough to stop the practice of defensive medicine, but when doctors are asked by their colleagues to justify the tests they ordered and the procedures they performed, perhaps they will be reminded that more is not always better.

Sunday, July 29, 2012

The Short Life and Lonely Death of Sabrina Seelig -

Just 22, she lived in a railroad flat in Bushwick, a part of Brooklyn that at the time was cheap but not yet hip, with a roommate who worked at the Museum of Modern Art. Ms. Seelig worked as a waitress in bistros on the Lower East Side while writing a novel and studying classics at Hunter College.

One night she stayed up all night translating a Latin text into English for a college paper. At 4 a.m. she e-mailed her professor saying she would deliver it in person. During the all-nighter, Ms. Seelig took Ephedra, a stimulant dietdrug that had been banned by the Food and Drug Administration three years earlier, and had a few beers. When she felt sick, she called Poison Control for help, and spoke very clearly, a recording of the call shows. She arrived by ambulance at Wyckoff Heights Medical Center, long regarded as one of the most troubled hospitals in the city, at 11:05 a.m. on May 30, 2007, conscious and alert but complaining of vomiting and dizziness.

She was given a sedative that put her into a deep sleep, and her wrists were tied to the bed. None of her friends or relatives knew that she was there, and medical records show no measurements of her vital signs for hours that afternoon, suggesting that she was left unattended by the medical staff.

By that evening she was brain damaged and on life support, with little hope of recovering. She died six days later.

Ms. Seelig's case brings to mind the death of Libby Zion, an 18-year-old Bennington College freshman who died in 1984, eight hours after being admitted to New York Hospital, where she had been sedated and tied down. Ms. Zion's death led to changes in the training of young doctors across the country, in a campaign led by her father, Sidney Zion, a well-connected New York writer.

But Ms. Seelig's grieving parents, Warren Seelig and Sherrie Gibson, carried on their crusade in private — and without the satisfaction of knowing that her death had changed the way medicine was practiced.

How could a 22-year-old woman die so abruptly? How could a youthful misstep have had such disastrous consequences? Those are questions the Seeligs still struggle to answer after five years. Because their daughter was alone at the hospital, they are left with only a sketchy record of her treatment and no way to know what she felt during her final hours. Her mother and her estate sued Wyckoff Hospital and staff members who had treated Ms. Seelig for malpractice, but they lost after an emotionally grueling four-week trial in the spring.

Asked what her daughter's biggest mistake might have been, Ms. Gibson said it was being young, carefree, adventurous and trusting.

"She had a wonderful innocent quality about her," said her friend Erin Durant, an aspiring songwriter who worked as a waitress with Ms. Seelig. "I don't mean that in a na├»ve way — that's a terrible word to use, innocent, but she was very, like, kind but real."

SABRINA was the younger of two sisters, and when she was little, her family lived in Philadelphia, where her parents taught at the University of the Arts. When she was 11, they moved to Rockland, Maine, a lobster town and artists' colony. She and her sister, Ashley, went skinny-dipping in the granite quarries. Their mother designed and sold clothing. Their father taught art and made ethereal sculptural forms that have been installed at places like the Pennsylvania Convention Center and the new American Embassy in Monrovia, Liberia.

When she was 13, she wanted to start an ice cream stand. Her father helped her build it, and they named it Lulu's, after their dog. The stand became a real business, a local phenomenon, and her sister still runs it today, with a small altar to Sabrina. "It has an authenticity about it, and Sabrina loved that kind of thing," Mr. Seelig said. "She is an old soul," he added, speaking of his younger daughter, still, in the present tense.

As a teenager, she directed plays, and her best friend, Caitlin FitzGerald, now an actress, starred in them. She graduated from high school a year early, in 2001, and took time off to travel before spending two years at Hampshire College in Amherst, Mass., attracted by its reputation for creativity. Then, restless again, she moved to New York, where her sister was in art school.

Ms. Seelig found an apartment at 70 St. Nicholas Avenue, five blocks from Wyckoff Hospital, and filled it with inspirational quotations from literature, shells from Maine and two paintings by her sister — "the only ones she ever liked," Ashley said, adding, "It was, like, extremely bohemian, like, oh, come on."

She drank Earl Grey tea with steamed milk, and wore flowing thrift-shop dresses.

Ms. Durant took her to the office of The Brooklyn Rail, a free, nonprofit journal of arts and politics based in Greenpoint, in a building just over the Pulaski Bridge from Long Island City, Queens, on a street so desolate it belongs in film noir. For Ms. Seelig, it was a sanctuary, almost like going home.

The Rail's publisher, Phong Bui, would let her visit in the middle of the night, after a shift as a waitress, so she could have a quiet place to write. "She would bring a bottle of wine or make coffee, depending on her mood," he said.

To David Varno, then The Rail's production editor, now getting a master's degree in creative writing at Columbia, it felt like a salon. "We would read books, talk about Walter Benjamin's 'Illuminations,' Dore Ashton's 'New York School,' " Mr. Varno said.

He went to her apartment for a couple of parties and saw her for the first time surrounded by her friends from Hampshire College, worldly, sophisticated and promising.

"They were all wearing these kind of fancy party dresses," he said. "I felt almost out of my element, but also happy to see that side of her, to see her in a more festive atmosphere."

Waiting on tables at the Pink Pony, on the Lower East Side, she met a regular customer, Jan Baracz, a Poland-born artist who was 25 years older than she was, and they started dating.

ON May 29, the day after Memorial Day, Ms. Seelig worked the dinner shift at Tree, a new restaurant in the East Village started by Colm Clancy, an Irish immigrant who had talked her into working for him.

She told Mr. Baracz that she could not see him because she had to go home to Bushwick to write her Latin paper. When her roommate, Colin Barry, left for work around 8 a.m. the next day, she was still at the kitchen table, papers spread out around her.

About 10:45 a.m., she called 911.

"I, I, I think I'm poisoned," she says on the recording of the call, which was provided to her parents after her death.

"I think after taking Ephedra, I looked online but I took Valerian, which is maybe poison, but I am having a hard time," she went on. Valerian is an herbal sleep remedy, which some toxicologists believe is a kind of placebo, with no medicinal qualities.

She added, "I've been vomiting for the past while, and my limbs feel heavy."

She hesitated only when asked her age. "Ah, 20-, 22, 23, no!" she cried. To her family, her confusion was understandable. Her birthday was two weeks away, on June 15.

The dispatcher asked if her door was unlocked, and she said she would go downstairs and unlock it.

When the ambulance did not come right away, she called the health department's Poison Control Center.

The Poison Control operator, a woman, told her to sit down and wait for the ambulance.

Ms. Seelig: When will they come?

Poison Control: When did you call them?

Ms. Seelig: I don't know. A while ago.

The operator, who seemed to be putting her off, asked if she could call a friend.

Ms. Seelig: I can, I did; they didn't answer.

Poison Control: Your mom?

Ms. Seelig: No. My mom is in a different state. I don't think it will help.

Poison Control, dismissively: Well maybe you could just talk to her for right now until the ambulance comes.

Ms. Seelig: O.K.

Poison Control: O.K. All right. Bye.

As the woman hung up and the line clicked, Sabrina could still be heard saying, "But help ..."

THE missed calls are part of the legacy of guilt and regret.

Before going to the hospital, Ms. Seelig called Mr. Baracz and a friend, Rebecca Green, but they did not pick up. She left no messages.

"Sometimes I think I have vibes," her mother said. "But I definitely had no vibes that morning or that day that anything was wrong. It just came out of the blue."

None of her friends had any inkling that anything was wrong until that night, when Ms. Seelig was supposed to host a dinner party. That afternoon, Mr. Baracz began calling about the menu. When she did not answer by 6 p.m., he sent a friend, Joanna Spinks, who lived around the corner, to look for her. The door to her apartment was unlocked and her laptop was on her bed, showing the Poison Control Web site. By calling 311, Mr. Baracz tracked her down at Wyckoff.

Ms. Spinks got to the hospital first, around 8 p.m., and then was joined by Ms. Green. They found Ms. Seelig in a small bed with a curtain around it. "She was there unconscious with all the tubes in her," Ms. Spinks said.

Her face looked normal, as if she were sleeping. "We were cutting up, like 'Earth to Sabrina,' " at her bedside, Ms. Green said, aghast at the memory.

Quickly, the guests from the canceled dinner party converged on the hospital.

Mr. Baracz, now 53, remembers asking a nurse what had happened. "You know what happened," she replied.

"Every hour they gave us a new explanation of what was happening," Ms. Green said. "When she was still asleep at 5 a.m., we knew something was wrong."

Mr. Baracz called Ms. Seelig's mother, who remembers being told by hospital staff that she should not rush to New York, that her daughter would come out of it by morning. Ignoring that advice, she and Mr. Seelig drove two hours to the airport in Portland that night and got to the hospital Thursday morning, where they were told that a constellation of specialists was being consulted.

Frustrated by a lack of clarity, Ms. Seelig's parents had her transferred to the Weill Cornell campus of NewYork-Presbyterian Hospital in Manhattan that evening; there, doctors tried a cooling therapy. Her friends held hands and sang. But it was too late. On June 4, 2007, Sabrina Seelig was declared brain-dead, and she was taken off life support the next day.

Ms. Seelig was an organ donor, so by the time of the autopsy, her body had already been carved up. The medical examiner concluded that she had died of "water intoxication," which usually means becoming overloaded with water without enough salt.

NO one is left to tell what Ms. Seelig was thinking or feeling before she died. The medical record, a jumble of handwritten notes, offers the only insight into her death. It came out over four weeks in May this year, at the trial for malpractice.

In 2007, when Ms. Seelig was a patient, the state ordered Wyckoff to hire a management consultant to improve its governance and finances. Five years later, it is still struggling. The Brooklyn district attorney has been investigating allegations of mismanagement. A three-month investigation by The New York Times, the results of which were published in March, found a history of insider dealing and positions being given to people with political ties. The hospital officials involved denied any wrongdoing. The hospital does not carry malpractice insurance.

In a pretrial deposition, an emergency-room doctor, Dali Mardach, remembered asking Ms. Seelig, "What's a nice-looking girl like you doing in Brooklyn?"

Dr. Mardach gave her two anti-nausea drugs, Phenergan and Tigan, which experts said can be sedating. As Ms. Seelig thrashed on the stretcher, Dr. Mardach ordered two doses of Ativan, a strong sedative, given intravenously at 1:15 and 1:45 p.m., for a total of four milligrams. She also ordered wrist restraints so that Ms. Seelig would not rip out her IV or hurt herself.

Much of the trial was a blur of technical detail. There was conflicting testimony as to whether Ms. Seelig was ever given oxygen. Her first blood test, which showed she was low on salt, was compromised; another test was not performed for hours. She was put in the care of a junior physician in training, Sameer Kaul, who found that she was "barely arousable." Dr. Mardach and the nurse, Joyce Smith, disagreed about which of them had found her when she crashed.

Most telling, all the witnesses agreed that there were no new vital signs entered in her chart for more than three hours, from 2:35 to 6:10 p.m., when she was found in a holding or overflow area with a racing heartbeat and foaming at the mouth. Ms. Smith said she had been watching Ms. Seelig's cardiac monitor constantly, so there was no need to write down her vital signs.

The plaintiffs' expert, Dr. Kelly Johnson-Arbor, argued that Ms. Seelig had been ignored while she suffered an agonizing death of hypoxia, or lack of oxygen, which if she were awake would have led to a feeling of being "suffocated," from the combined effects of the sedative drugs she had been given.

The defense argued that she had had a heart attack brought on by taking at least three Ephedra pills and whatever other drugs she might have taken. (The chart notes that she was "known" to take Focalin, an attention-deficit disorder drug commonly abused by college students to study.)

Late in the trial, as the plaintiffs' lawyer, Alan Fuchsberg, realized that it was going badly, he tried to suggest that the low salt level cited by the medical examiner should have been urgently treated, but a defense objection was sustained.

Dr. Johnson-Arbor stood alone against three defense experts, one for Dr. Mardach, one for the nurse and one for the hospital and its intern, Dr. Kaul. She was hugely pregnant; they were all middle-aged men in suits.

In his closing, the hospital's lawyer, Michael B. Lehrman, blamed Ms. Seelig for bringing about her own death with whatever cocktail of drugs she had taken. "You heard how confused she was," he said. "She couldn't even say her age. She was already in the process at that point of dying."

After a day and a half of deliberations, the jury of four men and two women returned its verdict: Wyckoff and the individuals working there had not been negligent.

The jury did not seem to identify with Ms. Seelig.

One juror, Marat Leychik, 23, an unemployed graduate of John Jay College of Criminal Justice who lives with his parents in Coney Island, said he had never had to use any stimulants, not even caffeine, to write a paper. "She, in my opinion, overexerted herself," he said.

Another juror, Irene Katzos, 39, a homemaker turned breadwinner from Bay Ridge, said that unlike Ms. Seelig she was "not artsy." When the Poison Control call was played, Ms. Katzos saw tears streaming down the face of Ms. Seelig's father, who was hearing the recording for the first time. "I swore I would never look over there again," she said.

After the trial, Dr. Eric D. Manheimer, former medical director of Bellevue Hospital Center in Manhattan, where he oversaw one of the busiest and most highly regarded emergency rooms in the country, reviewed Ms. Seelig's chart at the request of The Times and concluded that she had not been properly monitored.

As a precaution, doctors should have put a tube in her airway to keep her from breathing her own vomit and stomach acid and to provide oxygen, he said. And they should have moved her to intensive care. Her low salt could have been an additional "metabolic cause of stupor and coma," he said.

"It's not rocket science," Dr. Manheimer said. "Once your mental status is going down, you don't know when the person is going to stop breathing."

Ms. Seelig's parents are left with a July 2007 letter of condolence from Dr. Thomas R. Frieden, then New York City's health commissioner, whose office turned over the Poison Control recording.

"I wept after hearing the recording," Dr. Frieden, now head of the Centers for Disease Control and Prevention, wrote.

"As a parent, physician and fellow human being, I was deeply disturbed by the interaction of the Poison Control Center with your daughter," he wrote. Dr. Frieden said that the person who took the call "no longer works for the Poison Control Center," and that he was working on better coordination with 911.

For Mr. Seelig and Ms. Gibson, the letter serves as evidence that their daughter's death did matter to someone, and made some difference.

Asked what lesson might be taught by Sabrina's death, Ms. Gibson said there was one. "No one should go to a hospital without someone with you — no one," she said. "Don't go unless somebody at least knows you're there."

When the Doctor's Words Aren't Soothing -

I used to be a confident patient. I did not worry that tests would turn out badly. Well into adulthood, I was always reasonably healthy.
But over time, loved ones, close friends - and I - got tripped up by episodes of ill health, some from the far end of the statistical-probability universe. The unthinkable became reality. We were vulnerable.
Soon enough, each new medical test triggered greater anxiety in me. By now, I have morphed into one of those four-alarm, full-blown worriers, a card-carrying member of the 3 a.m. e-mail club. What else to do at that dark hour, except to lie awake, fearing the bad news that dawn may bring?
A medical professional's manner can provoke or soothe my apprehension. The doctors I interviewed for my article in this week's Science Times, "The Anxiety of Waiting for Test Results," spoke of the scripts they teach medical students to help prepare patients who are waiting for test results. Please, kids, don't cut these classes.
Once, after major surgery, I groggily came to as a young resident tiptoed toward me, looking nervous. My preoperative Pap smear, he said, came back as severely abnormal.
What does that mean, I whispered?
"We'll have to do more tests," he said solemnly, "but you may have cervical cancer."
His timing was wrong; his delivery was wrong. As nurses changed my surgical dressings, I wept, terrified.
Weeks later, follow-up tests. Normal. No cervical cancer. Not even close.
As I've lain on tables for ultrasounds, I've had technicians stare at monitors, shake their heads and whisper - and look away. Except for the one who said, "Wow, you're just coming to us now? You mean you never felt that?"
But perhaps the prize for worst delivery goes to the doctor of a friend who was waiting for results of her young child's leukemia treatment.
On a Thursday afternoon before a long holiday weekend, the doctor left a voice mail message: "Hi! The results are in. They're still a little abnormal. We should talk. Call my office Monday morning to make an appointment."
But there have also been moments of grace. I will always remember another radiology technician, who, as I shook with fear after an M.R.I. scan, folded me in her arms, whispering prayers in my ear.
Once, after I'd had a biopsy, the doctor who performed it, a chilly stranger, refused to let my regular doctor tell me results. Her procedure, her phone call.
A nurse pulled me aside. "Don't worry," she said. "If she doesn't change her mind, I'll make sure your doctor sees your results first. At the very least, you deserve that much." That nurse kept her promise.
Finally, there was the unexpected turn of events following a miserable stretch of 10 days after a PET scan: metastatic cancer, yes or no? My oncologist promised to call immediately. He knows how I get.
By my calculation, I was likely to hear from him the following Thursday, sometime between 1:15 p.m. and 1:30 p.m.
But the day before the call was to come, I got a last-minute assignment. On that Thursday I would be in Atlanta, reporting for an article due Friday morning.
If my cellphone were to ring with a life-altering message, how could I concentrate?
Please, I begged the doctor's nurses and secretary, via e-mail, voice mail and direct calls: Ask him to postpone the call until Friday afternoon.
That Thursday I was in a kitchen in suburban Atlanta, conducting my interview, having compartmentalized my fear. Suddenly my cellphone buzzed. It was my doctor. I grew pale, but didn't answer.
The words of the person I was interviewing became lost in a wind tunnel. Shakily I excused myself and fled to a bathroom. I couldn't not listen to the voice message.
"Hi, it's Larry," my doctor said. "I got your messages. I know, I'm not supposed to call. Sorry to disappoint you. But I thought you'd like to know as soon as possible. Normal. The results are normal. Have a good day."

Too Few Doctors in Many U.S. Communities -

RIVERSIDE, Calif. — In the Inland Empire, an economically depressed region in Southern California, President Obama's health care law is expected to extend insurance coverage to more than 300,000 people by 2014. But coverage will not necessarily translate into care: Local health experts doubt there will be enough doctors to meet the area's needs. There are not enough now.

Other places around the country, including the Mississippi Delta, Detroit and suburban Phoenix, face similar problems. The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. And that number will more than double by 2025, as the expansion of insurance coverage and the aging of baby boomers drive up demand for care. Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000.

Health experts, including many who support the law, say there is little that the government or the medical profession will be able to do to close the gap by 2014, when the law begins extending coverage to about 30 million Americans. It typically takes a decade to train a doctor.

"We have a shortage of every kind of doctor, except for plastic surgeons and dermatologists," said Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, founded in part to address the region's doctor shortage. "We'll have a 5,000-physician shortage in 10 years, no matter what anybody does."

Experts describe a doctor shortage as an "invisible problem." Patients still get care, but the process is often slow and difficult. In Riverside, it has left residents driving long distances to doctors, languishing on waiting lists, overusing emergency rooms and even forgoing care.

"It results in delayed care and higher levels of acuity," said Dustin Corcoran, the chief executive of the California Medical Association, which represents 35,000 physicians. People "access the health care system through the emergency department, rather than establishing a relationship with a primary care physician who might keep them from getting sicker."

In the Inland Empire, encompassing the counties of Riverside and San Bernardino, the shortage of doctors is already severe. The population of Riverside County swelled 42 percent in the 2000s, gaining more than 644,000 people. It has continued to grow despite the collapse of one of the country's biggest property bubbles and a jobless rate of 11.8 percent in the Riverside-San Bernardino-Ontario metro area.

But the growth in the number of physicians has lagged, in no small part because the area has trouble attracting doctors, who might make more money and prefer living in nearby Orange County or Los Angeles.

A government council has recommended that a given region have 60 to 80 primary care doctors per 100,000 residents, and 85 to 105 specialists. The Inland Empire has about 40 primary care doctors and 70 specialists per 100,000 residents — the worst shortage in California, in both cases.

Moreover, across the country, fewer than half of primary care clinicians were accepting new Medicaid patients as of 2008, making it hard for the poor to find care even when they are eligible for Medicaid. The expansion of Medicaid accounts for more than one-third of the overall growth in coverage in President Obama's health care law.

Providers say they are bracing for the surge of the newly insured into an already strained system.

Temetry Lindsey, the chief executive of Inland Behavioral & Health Services, which provides medical care to about 12,000 area residents, many of them low income, said she was speeding patient-processing systems, packing doctors' schedules tighter and seeking to hire more physicians.

"We know we are going to be overrun at some point," Ms. Lindsey said, estimating that the clinics would see new demand from 10,000 to 25,000 residents by 2014. She added that hiring new doctors had proved a struggle, in part because of the "stigma" of working in this part of California.

Across the country, a factor increasing demand, along with expansion of coverage in the law and simple population growth, is the aging of the baby boom generation. Medicare officials predict that enrollment will surge to 73.2 million in 2025, up 44 percent from 50.7 million this year.

"Older Americans require significantly more health care," said Dr. Darrell G. Kirch, the president of the Association of American Medical Colleges. "Older individuals are more likely to have multiple chronic conditions, requiring more intensive, coordinated care."

The pool of doctors has not kept pace, and will not, health experts said. Medical school enrollment is increasing, but not as fast as the population. The number of training positions for medical school graduates is lagging. Younger doctors are on average working fewer hours than their predecessors. And about a third of the country's doctors are 55 or older, and nearing retirement.

Physician compensation is also an issue. The proportion of medical students choosing to enter primary care has declined in the past 15 years, as average earnings for primary care doctors and specialists, like orthopedic surgeons and radiologists, have diverged. A study by the Medical Group Management Association found that in 2010, primary care doctors made about $200,000 a year. Specialists often made twice as much.

The Obama administration has sought to ease the shortage. The health care law increases Medicaid's primary care payment rates in 2013 and 2014. It also includes money to train new primary care doctors, reward them for working in underserved communities and strengthen community health centers.

But the provisions within the law are expected to increase the number of primary care doctors by perhaps 3,000 in the coming decade. Communities around the country need about 45,000.

Many health experts in California said that while they welcomed the expansion of coverage, they expected that the state simply would not be ready for the new demand. "It's going to be necessary to use the resources that we have smarter" in light of the doctor shortages, said Dr. Mark D. Smith, who heads the California HealthCare Foundation, a nonprofit group.

Dr. Smith said building more walk-in clinics, allowing nurses to provide more care and encouraging doctors to work in teams would all be part of the answer. Mr. Corcoran of the California Medical Association also said the state would need to stop cutting Medicaid payment rates; instead, it needed to increase them to make seeing those patients economically feasible for doctors.

More doctors might be part of the answer as well. The U.C. Riverside medical school is hoping to enroll its first students in August 2013, and is planning a number of policies to encourage its graduates to stay in the area and practice primary care.

But Dr. Olds said changing how doctors provided care would be more important than minting new doctors. "I'm only adding 22 new students to this equation," he said. "That's not enough to put a dent in a 5,000-doctor shortage."